Ralat: Pasien 1 Management: Cefixime 200mg/12hr Pasien 2 Planning: Consult To Subdivisi Lens

Ralat :
Pasien 1
Management :
Cefixime 200mg/12hr
Pasien 2
Planning :
Consult To Subdivisi Lens
Case Report
Lateral Orbitotomy Technique with

Stallard-Wright Incision in Proptosis Cases
et causa suspect Lacrimal Gland Tumor
Lilianty Fauzi*
Consultant:
dr. Riani Erna, Sp.M (K)
OPHTHALMOLOGY DEPARTMENT OF SRIWIJAYA UNIVERSITY

MOH. HOESIN HOSPITAL PALEMBANG
2018
Introduction
Benign Malignant
lesions lesions
Adenoid cystic
pleomorphic
carcinoma
adenoma
66%
Dacryop Pleomorphic
adenocarcino
> 50% ma 18%
Primary
Shields JA in 2002 adenocarcino
reported that a number ma 9%
of orbital lesions most
mukoepiderm
commonly found were oid carcinoma
from the lacrimal gland. 3%
The choice approach for intraorbital lesions : the
location of the tumor, the size of the lesion, and
possible anticipated pathology
The approach chosen is that which can restore

intraorbital anatomical structure and function
properly, and provide good cosmetic results
Management in cases of proptosis caused by

lacrimal gland tumors is surgery with a Lateral
Orbitotomy with a Stallard-Wright incision
AIM
To find out more about

Lateral Orbitotomy
techniques used in cases of
proptosis caused by suspect
lacrimal gland tumors
Case Report
IDENTIFICATION 1
Name • Mr. W
Age • 19 years old
Gender • Male
Date visite • 3rd August 2018
Address • Out Of Town

Patient 1
Auto Anamnesis
:
Chief Complain
Left Eye Protrude since 6

month ago
Case Report 1
History :
• Left eye protude, Blurred

6 Month Ago vision(-), red eye(-),pain(-)
• Left eye protude became

3 Months Ago bigger, and patient Getting
Alternative medicine
10
Case Report 1
• Patient felt there was no

1 Month change and the eyes became more
bigger patient went to private hospital
Ago in Palembang and finally was referred
to Moh. Hoesin Hospital Palembang
Case Report 1
oOpera
otion
History of Past
Ilness
family
with
No
same oTrauma
Hystory
complai
nts
owearin
g spec
otacles
Physical Examination
Sensorium • Compos Mentis
Blood Pressure • 120/80mmHg
Pulse • 74 x/minute
Respiratory Rate • 18 x/minute
Temperature • Afebris
13
No swollen
lymph
node
• Neck detected
• Axilla
• clavicula
• Pre auricular
• Inguinal
Ophthalmology Examination
August 3rd RE LE
2018
Visual Acuity 6/6 6/6
IOP 16,5 mmHg 18,9 mmHg

Eyeball Alignment Proptosis (Non Axial displacement)
18 116 25
Eye movement
Eyelid MRD 1 = 5 mm
MRD 1 = 4 mm
MRD 2 = 7 mm
MRD 2 = 7 mm
FP = 11 mm
FP = 11 mm
LA = 14
LA = 14 16
Lagoftalmus (-)
RE LE
Conjunctiva Normal limit Normal limit
Cornea Clear Clear

Anterior chamber Normal depth Normal depth
Iris Good appearance Good appearance
Pupil Round, central, Ø 3 Round, central, Ø 3
mm, light reflex (+) mm, light reflex (+)
RAPD (-) RAPD (-)
Lens Clear Clear
17
RE LE
Posterior Segment Fundus reflex (+) Fundus reflex (+)

Optic nerve head Round, clear margin, Round, clear margin,
normal colour, c/d normal colour, c/d
0.3; a/v:2/3 0.3; a/v:2/3
Macula FR (+) FR (+)

Retina Normal vascular Normal vascular
contour contour
18
Local Status
• Mass on the superotemporal region on the

Inspection left eye, Non Axial , same colour with other
No retraction of palpebra
• Mass on the superotemporal region on the left

eye, Size ± 2x2x1 cm, firm-hard consistency,
Palpation unable to move from the base, flat surface,
tenderness (-)
19
CT Scan
Interpretation:
Radiologically invisible
intracerebral abnormalities
Left intraorbita SOL suspect

with proptosis OS dd/
pseudotumor
Different Diagnose
1. Proptosis OS ec suspect Adenocarcinoma

Lacrimal Gland
2. Proptosis OS ec suspect Pleomorfik Adenoma
Working Diagnose
Proptosis OS ec suspect Adenocarcinoma

Lacrimal Gland
Planning
• Informed consent
• Check laboratorium and rontgen thoraks
• Pro consul internist and anesthesi
• Pro Lateral Orbitotomy OS
Prognosis
Quo ad
fungsionam
Quo ad Quo ad
vitam sanationam
Dubia
ad
Malam
3
4
2
IntraOperative 5
8
7
Tumor Description :
size is 3 x 2.5 x 1.5 mm,

brownish white color,
uneven surface, hard
consistency
Follow Up 1
August 16 RE LE
2018
Visual Acuity 6/6 6/7,5 ph 6/6

Eyeball Alignment Orthoforia
18 116 20
Eye movement
Eyelid Edema (+), Look good suture at

superior palpebrae from the
Normal medial anterior to lateral along
35 mm,blood (-), pus (-), drain
(+) 5 cc
27
RE LE
Conjunctiva Normal limit Kemosis (+) in Lateral

region
Cornea Clear Clear
RAPD (-) RAPD (-)
Lens Clear Clear
28
RE LE

0.3; a/v:2/3 0.3; a/v:2/3

contour contour
29
Eye Description
Diagnose
Post Lateral Orbitotomy OS ai Proptosis OS
ec suspect Adenocarcinoma Lacrimal Gland
Management
1. Cefixime 200mg/12hr
2. Asam Mefenamat 500mg/8hr
3. Asam tranexamat 500mg/8hr
4. Levofloxacin ED 1 gtt/4hr
5. Chloramfenicol EO ue/4hr
6. Methylprednisolon Injection 125mg/ 8hr
Follow Up 2
August 17th RE LE
2018

18 116 20
Eye movement
Eyelid Edema (+), Hematom (+), Look

good suture at superior palpebrae
Normal from the medial anterior to lateral
along 35 mm,blood (-), pus (-),
drain (+) 3 cc 33
RE LE
Conjunctiva Normal limit Subconjungtiva

Bleeding (+)
Cornea Clear Clear
RAPD (-) RAPD (-)
Lens Clear Clear
34
RE LE

0.3; a/v:2/3 0.3; a/v:2/3

contour contour
35
Eye Description
Diagnose
Post Orbitotomy Lateral OS ai Proptosis OS
Management
August 18 RE LE
2018

18 116 20
Eye movement
Eyelid Edema (+), Hematom (+), Look

good suture at superior palpebrae
Normal from the medial anterior to lateral
along 35 mm,blood (-), pus (-),
drain (+) 0 cc 39
RE LE
Conjunctiva Normal limit Subkonjungtiva

Bleeding (+)
Cornea Clear Clear
RAPD (-) RAPD (-)
Lens Clear Clear
40
RE LE

0.3; a/v:2/3 0.3; a/v:2/3

contour contour
41
Eye Description
Diagnose
Post Orbitotomy Lateral OS ai Proptosis OS
Management
7. Out of patient, Revisite 1 week later
Histopathology
Examination
23 August
2018
Primary ductal adenocarcinoma

probably originates from the
retroorbital lacrimal gland
IDENTIFICATION 2
Name • Mr. M
Age • 65 years old
Gender • Male
Date visite • 3rd August 2018
Address • Out Of Town

Patient 2
Auto Anamnesis
:
Chief Complain
Right Eye Protrude

since 2 month ago
Case Report 2
History :
• Right eye protude, Blurred
vision(-), Decreased vision (-),
2 Month Ago red eyes (-) pain (-), watery
eyes (-), seeing like cloudy (+)
• Patient went to private hospital

in Palembang and finally was
1 Month Ago referred to Moh. Hoesin Hospital
Palembang
47
Case Report 2
oHiperte
nsion
family
with
oDiabet
same
es
complai
nts
History of Past No
Hystory
Ilness
owearin
Opera
g spec
otion
otacles
oTrauma
Physical Examination
Sensorium • Compos Mentis
Blood Pressure • 120/70mmHg
Pulse • 72 x/minute
Respiratory Rate • 22 x/minute
Temperature • Afebris
49
No swollen
lymph
node
• Neck detected
• Axilla
• clavicula
• Pre auricular
• Inguinal
August 3rd RE LE
2018
Visual Acuity 1/300 6/21 ph (-)

Eyeball Alignment Proptosis (Non Axial displacement)
21 112 12
Eye movement
Eyelid Normal Limit Normal Limit
52
RE LE
Conjunctiva Normal limit Normal limit
Cornea Clear Clear

RAPD (-) RAPD (-)
Lens Cloudy (+) St (-) Cloudy, N I
53
RE LE
Posterior Segment Fundus reflex (-) Fundus reflex (+)

Optic nerve head details difficult to Round, clear margin,
value normal colour, c/d
0.3; a/v:2/3
Macula details difficult to FR (+)

value
Retina details difficult to Normal vascular
value contour
54
Local Status
• Mass on the superotemporal region on the

Inspection Right eye, Non Axial , same colour with
other No retraction of palpebra
• Mass on the superotemporal region on the left

Palpation eye, Size ± ± 1,5 x1,5 x1 cm, soft consistency,
mobile , flat surface, tenderness (-)
55
CT Scan
Soft tissue mass lobulated size 2 x 2.5 cm at superolateral extra

oculi of the right orbital cavit, which is partially difficult to separate
from the rectus superior and lateral muscles of the anterior side
push the oculi bulbi to anteromedial right.
Different Diagnose
1. Proptosis OD ec suspect Pleomorfik Adenoma with
Cataract matur OD + Cataract nuclearis grade 1 OS
2. Proptosis OD ec suspect Adenocarcinoma Kelenjar
Lakrimal with Cataract matur OD + Cataract nuclearis
grade 1 OS
Working Diagnose
Proptosis OD ec suspect Pleomorfik Adenoma with Cataract

matur OD + Cataract nuclearis grade 1 OS
Planning
• Informed consent
• Check laboratorium and rontgen thoraks
• Pro consul internist and anesthesi
• Pro Lateral Orbitotomy OD
Prognosa
Quo ad vitam:
Bonam
Quo ad Quo ad
Functionam: Sanationam:
Bonam Bonam
4
3
2
1 5
IntraOperative
8
6
7
Tumor Description :
size is 2 x 2 x 2,5 mm
mm, brownish white
color, flat surface,
elastic consistency
Follow Up 1
Septemb 11 RE LE
2018

14 112 12
Eye movement
Eyelid Edema (+), Hematom (+), Look good

suture at superior palpebrae from the
Normal Limit
medial anterior to lateral along 35
mm,blood (-), pus (-), drain (+) 3 cc
63
RE LE
Conjunctiva Kemosis, lateral Normal limit

region
Cornea Clear Clear
RAPD (-) RAPD (-)
64
RE LE

Optic nerve head Details difficult to Round, clear margin,
0.3; a/v:2/3
Macula Details difficult to FR (+)

value
Retina Details difficult to Normal vascular
value contour
65
Eye Description
Diagnose
Post Orbitotomy Lateral OD ai Proptosis OD ec
suspect Pleomorfik Adenoma with Cataract matur OD
+ Cataract nuclearis grade 1 OS
Management
3. Chloramfenicol EO/8hr
5. Methylprednisolon 8mg/8hr
Follow Up 2
Septemb 12 RE LE
2018

14 112 12
Eye movement
Eyelid Edema (+), Hematom (+), Look good

suture at superior palpebrae from the
Normal Limit
medial anterior to lateral along 35
mm,blood (-), pus (-), drain (+) 0 cc
69
RE LE
Conjunctiva Kemosis, lateral Normal limit

region
Cornea Clear Clear
RAPD (-) RAPD (-)
70
RE LE

Optic nerve head Details difficult to Round, clear margin,
0.3; a/v:2/3
Macula Details difficult to FR (+)

value
Retina Details difficult to Normal vascular
value contour
71
Eye Description
Diagnose
Post Orbitotomy Lateral OD ai Proptosis OD ec
suspect Pleomorfik Adenoma with Cataract matur OD
+ Cataract nuclearis grade 1 OS
Management
3. Chloramfenicol EO/8hr
5. Methylprednisolon 8mg/8hr
6. Out of patient, Revisite 1 week later
Histopathology
Examination
21 September
2018
Pleomorfik adenoma at
Superior eyelid oculi sinistra
Discussion
Case 1 Case 2
Young Age (19th) Old Age (65th)
Malignant Lacrimal Benign Lacrimal Gland

Gland Tumor Tumor
Ct-Scan : Mass In retroorbital

lateral region, ekstraconal space
Lateral Orbitotomy with

Stallard-Wright Incision
Mass removed In toto

William B.
Stewart, et All
pada tahun 2011
The success rate of
Lateral Orbitotomy in the
superior temporal area
of 77.4% can be removed
in toto through a Lateral
Orbitotomy with a
Stallard-Wright incision
Conclussion
Possibility of facial
nerve damage is
minimal
Get broad orbital

room exposure until oinvisible scar
to posterior
restore anatomical Lateral

structure and Tumor can be
Orbitotomy removed as a whole
function properlyAge
different get Orbita with Stallard- (In toto)
tumor Wright
Thank You
Dinding Orbita
“ Corkscrew “ pelebaran pembuluh darah episklera
dengan dasar konjungtiva yang putih
karena statis pembuluh darah.
“ Bruit “ suara aliran darah yang terdengar pada

pemeriksaan dengan stetoskop dan sebagai tanda
Khas dari Arteri Vena fistula.
Pseudotumor
• Inflamasi orbita yg khas, merupakan proses

idiopatik, kdg suatu lokal spesifik atau penyakit
sistemik sebagai penyebab
• Inflamasi pd jaringan orbita, terdiri atas limfosit &
sel-sel plasma
• Diagnosis b’dasarkan gjala klinis didukung oleh CT
Scan orbita.
• Penanganan : respon baik thd kortikosteroid
sistemik m’bantu penegakan diagnosis
Kelenjar lakrimalis terdiri dari struktur-struktur berikut ini: 6
• Lobus Orbita berbentuk kenari, terletak di dalam fossa glandulae
lakrimalis di segmen temporal atas anterior orbita yang dipisahkan dari
bagian palpebra oleh kornu lateralis muskulus levator palpebra. Untuk
mencapai bagian kelenjar ini dengan pembedahan, harus diiris kulit,
muskulus orbikularis okuli, dan septum orbita.
• Lobus Palpebra yang lebih kecil terletak tepat di atas segmen temporal
forniks konjungtiva superior. Duktus sekretorius lakrimal, yang bermuara
pada sekitar 10 lubang kecil, yang mengubungkan bagian orbita dan
bagian palpebra kelenjar lakrimal dengan forniks konjungtiva superior.
Pengangkatan bagian palpebra kelenjar akan memutus semua saluran
penghubung dan mencegah seluruh kelenjar bersekresi.
• RAPD (Relative Afferent Pupillary
Defect): Kelainan pupil pada kerusakan
aferen (nervus optikus). Teknik
pemeriksaan dengan swinging light
reflect. Pada mata dengan RAPD (+)
terjadi penurunan konstriksi pupil bila
diberikan cahaya langsung sekitar 5 s (5
detik).

Ralat: Pasien 1 Management: Cefixime 200mg/12hr Pasien 2 Planning: Consult To Subdivisi Lens

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Ralat: Pasien 1 Management: Cefixime 200mg/12hr Pasien 2 Planning: Consult To Subdivisi Lens

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Ralat :

Lateral Orbitotomy Technique with

OPHTHALMOLOGY DEPARTMENT OF SRIWIJAYA UNIVERSITY

The approach chosen is that which can restore

Management in cases of proptosis caused by

To find out more about

Age • 19 years old

Date visite • 3rd August 2018

Address • Out Of Town

Left Eye Protrude since 6

• Left eye protude, Blurred

• Left eye protude became

• Patient felt there was no

Sensorium • Compos Mentis

Blood Pressure • 120/80mmHg

Respiratory Rate • 18 x/minute

Visual Acuity 6/6 6/6

IOP 16,5 mmHg 18,9 mmHg

Conjunctiva Normal limit Normal limit

Cornea Clear Clear

Posterior Segment Fundus reflex (+) Fundus reflex (+)

Macula FR (+) FR (+)

• Mass on the superotemporal region on the

• Mass on the superotemporal region on the left

Left intraorbita SOL suspect

1. Proptosis OS ec suspect Adenocarcinoma

Proptosis OS ec suspect Adenocarcinoma

size is 3 x 2.5 x 1.5 mm,

Visual Acuity 6/6 6/7,5 ph 6/6

IOP 16,5 mmHg 18,0 mmHg

Eyelid Edema (+), Look good suture at

Conjunctiva Normal limit Kemosis (+) in Lateral

Posterior Segment Fundus reflex (+) Fundus reflex (+)

Macula FR (+) FR (+)

Visual Acuity 6/6 6/7,5 ph 6/6

IOP 15,6 mmHg 18,3 mmHg

Eyelid Edema (+), Hematom (+), Look

Conjunctiva Normal limit Subconjungtiva

Posterior Segment Fundus reflex (+) Fundus reflex (+)

Macula FR (+) FR (+)

Visual Acuity 6/6 6/7,5 ph 6/6

IOP 15,6 mmHg 18,3 mmHg

Eyelid Edema (+), Hematom (+), Look

Conjunctiva Normal limit Subkonjungtiva

Posterior Segment Fundus reflex (+) Fundus reflex (+)

Macula FR (+) FR (+)

Primary ductal adenocarcinoma

Age • 65 years old

Date visite • 3rd August 2018

Address • Out Of Town

Right Eye Protrude

• Patient went to private hospital

Sensorium • Compos Mentis

Blood Pressure • 120/70mmHg

Respiratory Rate • 22 x/minute

Visual Acuity 1/300 6/21 ph (-)

IOP 16,5 mmHg 18,0 mmHg

Eyelid Normal Limit Normal Limit

Conjunctiva Normal limit Normal limit

Cornea Clear Clear

Posterior Segment Fundus reflex (-) Fundus reflex (+)

Macula details difficult to FR (+)

• Mass on the superotemporal region on the